Suburban Emergency Department Research Articles

Operation STICK: A vascular access specialty program for the generalist emergency medicine clinician.

Comprehensive education and training programs are urgently needed to improve vascular access outcomes in the emergency department (ED). This study aimed to demonstrate the success of a formalized vascular access program in developing competent ED clinicians in traditional and ultrasound-guided insertion methods. This was a retrospective observational study exploring the success of trainees in obtaining competency in peripheral vascular access at an academic suburban ED with 120,000 annual visits. Eligible participants included healthcare workers that enrolled in the Operation STICK vascular access program and perform vascular access procedures as an aspect of their clinical practice. Competency in vascular access included both traditional and ultrasound-guided (US) peripheral intravenous catheter (PIVC) insertions. Competency was defined as demonstration of successful insertion of one traditional and one US PIVC in compliance with checklist. The primary objective was competency. Secondary objectives included trainee time to competency, trainee number of line encounters, and changes in program competency achievements over time. From October 15, 2021, to April 15, 2023, 141 clinicians participated in peripheral vascular access training via the Operation STICK model, which included 72 (51.1%) nurses, 52 (36.9%) ED technicians, and 17 (12.0%) healthcare personnel with other medical training. Clinicians overall reported an average of 5.6 years of experience inserting peripheral intravenous catheters (PIVCs) and 23 (16.3%) had experience with using ultrasound. About 122 (86.5%) clinicians successfully completed the program and demonstrated competency in traditional and ultrasound-guided techniques. Time to competency varied over time, with a median of 124 days in the early phase, 32.5 days middle phase, and 10.6 h over 9.5 days in the later phase of the program (p < 0.001). Achieving competency in PIVC insertion necessitates a focused effort on refining and systematizing education and training approaches. Recognizing the inherent challenges present in ED settings, it is feasible to effectively and efficiently train emergency clinicians to be expert in both basic and advanced PIVC placement techniques through participation in a well-organized vascular access training program.

Transcutaneous electrical nerve stimulation (TENS) versus sham TENS in adult ED patients with abdominal pain: A clinical trial

ObjectiveThere is a growing consensus that the risks of current pharmacologic analgesics warrant consideration of alternative modalities for acute and chronic pain control. The objective of this study was to evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) in adult emergency department (ED) patients presenting with abdominal pain. MethodsWe conducted a patient and observer blinded randomized controlled trial comparing TENS to sham TENS. The study was conducted at a large suburban academic ED. Patients with abdominal pain and a verbal numeric pain scale (VNS) of 5 or greater were randomized to TENS or sham TENS applied via 4 skin pads, one in each abdominal quadrant for 30 min. The primary outcome was change in pain scores 30 min after the intervention. Our study had 80% power to detect a between group difference of 1.5 points on the VNS. Results81 patients were randomized to TENS (n = 41) or sham TENS (n = 40). Groups were similar in baseline characteristics. The mean (SD) reductions in pain scores were 1.9 (2.1) and 1.7 (2.6) in patients treated with TENS and sham TENS respectively (P = 0.81). Use of rescue medications in patients with treated with TENS and sham TENS was similar (49 vs 55% respectively, P = 0.66). ConclusionsApplication of TENS to the abdominal wall did not result in more effective pain relief than sham TENS in adult ED patients with abdominal pain.

Hemolyzed Laboratory Specimens in the Emergency Department: An Underappreciated, but Frequent Problem

IntroductionHemolysis of blood samples from emergency department (ED) patients leads to delays in treatment and disposition. The aim of this study is to determine the frequency of hemolysis and variables predictive of hemolysis. MethodsThis observational cohort study was conducted among three institutions: academic tertiary care center and two suburban community EDs, with an annual census of over 270,000 ED visits. Data were obtained from the electronic health record. Adults requiring laboratory analysis with at least one peripheral intravenous catheter (PIVC) inserted within the ED were eligible. Primary outcome was hemolysis of lab samples and secondary outcomes included variables related to PIVC failure. ResultsBetween January 8, 2021 and May 9, 2022, 141,609 patient encounters met inclusion criteria. The average age was 55.5 and 57.5% of patients were female. Hemolysis occurred in 24,359 (17.2%) samples. In a multivariate analysis, when compared to 20-gauge catheters, smaller 22-gauge catheters had an increased odds of hemolysis (OR 1.78, 95% confidence interval (CI) 1.65-1.91; P < .001), while larger 18-gauge catheters had a lower odds of hemolysis (OR 0.94; 95% CI 0.90-0.98; P = .0046). Additionally, when compared to antecubital placement, hand/wrist placement demonstrated increased odds of hemolysis (OR 2.06; 95% CI 1.97-2.15; P < .001). Finally, hemolysis was associated with a higher rate of PIVC failure (OR 1.06; 95%CI 1.00-1.13; P = 0.043). DiscussionThis large observational analysis demonstrates that lab hemolysis of is a frequent occurrence among ED patients. Given the added risk of hemolysis with certain placement variables, clinicians should consider catheter gauge/placement location to avoid hemolysis that may result in patient care delays and prolonged hospital stays.

Effects of California's New Patient Homelessness Screening and Discharge Care Law in an Emergency Department.

Introduction California State Bill 1152 (SB1152) mandated all non-state-operated hospitals meet specific criteria when discharging patients identified as experiencing homelessness. Little is known about SB1152's effect on hospitals or compliance statewide. We studied the implementation of SB1152 in our emergency department (ED). Methods We analyzed our suburban academic ED's institutional electronic medical record for one year before (July 1, 2018-June 20, 2019) and one year after (July 1, 2019-June 30, 2020) implementation of SB1152. We identified individuals by lack of address during registration, International Classification of Diseases, Tenth Revision (ICD-10) code of homelessness, and/or the presence of an SB1152 discharge checklist. Demographics, clinical information, and repeat visit data were collected. Results ED volumes were constant during the pre- and post-SB1152 periods (approximately 75,000 annually); however, ED visits by people experiencing homelessness more than doubled (630 (0.8%) to 1530 (2.1%) in the pre- and post-implementation periods.Age and sex distributions were similar with approximately 80% of patients aged 31-65 years and less than 1% under 18. Visits by females comprised less than 30% of the population. Visits by people of the White race decreased from 50% to 40% pre- and post-SB1152. Visits by people of the Black, Asian, and Hispanic races experiencing homelessness increased by 18% to 25%, 1% to 4%, and 19% to 21%, respectively. Acuity was unchanged with 50% of visits classified as "urgent."Discharges increased from 73% to 81% and admissions halved from 18% to 9%. Visits by patients with only one ED visit decreased (28% to 22%); those with four or more visits increased (46% to 56%). The most common primary diagnoses pre- and post-SB1162 were alcohol use (6.8% and 9.3%, respectively), chest pain (3.3% and 4.5%, respectively), convulsions (3.0%, and 2.46%, respectively), and limb pain (2.3% and 2.3%, respectively). The primary diagnosis of suicidal ideation doubled from the pre- to post-implementation periods (1.3% to 2.2%, respectively). Checklists were completed for 92% of identified patients discharged from the ED. Conclusion Implementation of SB1152 in our ED resulted in identifying an increased number of persons experiencing homelessness. We identified opportunities for further improvement since pediatric patients were missed. Further analysis is warranted, especially with the coronavirus disease 2019 (COVID-19) pandemic, which has significantly affected healthcare-seeking behavior in EDs.

Comparison of anaphylaxis epidemiology between urban and suburban pediatric emergency departments

BackgroundAnaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. To date, there are no published data on epidemiology of pediatric anaphylaxis in Michigan. Our objective was to describe and compare the time trends in incidence of anaphylaxis in urban and suburban populations of Metro Detroit.MethodsWe performed a retrospective study of Pediatric Emergency Department (ED) anaphylaxis visits from January 1, 2010, to December 1, 2017. The study was conducted at 1 suburban ED (SED) and 1 urban ED (UED). We identified cases using an International Classification of Diseases (ICD) 9 and 10 query of the electronic medical record. Patients were included if they aged 0–17 years and met the 2006 National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network diagnostic criteria for anaphylaxis. The anaphylaxis rate was calculated as the number of detected cases divided by the total number of pediatric emergency room visits for that month. Anaphylaxis rates were compared between the two EDs using Poisson regression.ResultsA total of 8,627 patient encounters had ICD codes for anaphylaxis, of which 703 visits fulfilled the inclusion criteria and were used in subsequent analyses. Overall, the incidence of anaphylaxis was more common in males and in children < 4 years of age in both centers. Although the total number of anaphylaxis related visits was higher at UED over the eight-year time frame for this study, the anaphylaxis rate (cases per 100,000 ED visits) throughout the study was higher at the SED. While the observed anaphylaxis rate at UED was 10.47 – 162.05 cases per 100,000 ED visits, the observed anaphylaxis rate at SED was 0 – 556.24 cases per 100,000 ED visits.ConclusionPediatric anaphylaxis rates differ significantly between urban and suburban populations in metro Detroit EDs. The rate of anaphylaxis related visits to the ED has significantly increased over the past 8 years in the metro Detroit area, with significantly higher rise in suburban compared to urban ED. More studies are needed to explore the reasons for this observed difference in increase rates.

Hyponatremia and hypernatremia in the emergency department: severity and outcomes.

Hyponatremia and hypernatremia are common electrolyte disorders. Few studies to date have focused on patients presenting to the emergency department (ED) with sodium (Na) disorders. Our objective was to determine the incidence and outcomes of hyponatremia and hypernatremia in ED patients. This study was a retrospective, single-center review of electronic medical records at an academic suburban ED with approximately 100,000 annual visits. Subjects included consecutive adult ED patients with Na levels measured while in the ED in 2019. Demographic, clinical, and laboratory data were recorded. Outcomes data, including hospital admission, intensive care unit (ICU) admission, mortality, and length of stay (LOS), were recorded. The primary outcome was inhospital death. Secondary outcomes were hospital admission, ICU admission, ED LOS, and hospital LOS. Univariable and multivariable linear and logistic regression analyses were performed to explore the association of candidate predictor variables and outcomes. Na was measured in 57,427 adults (54%) among a total of 106,764 assessed ED visits in 2019. The mean±standard deviation age was 54±21 years, and 47% of participants were male. Mild, moderate, and severe hyponatremia and hypernatremia occurred in 8%, 2%, and 0.1% of patients and 1%, 0.2%, and <0.1% of patients, respectively. Hospital and ICU admission and mortality rates increased as Na levels increased or decreased further from normal. Adjusted odds ratio (95% confidence interval) values for hospital mortality were 2.39 (1.97-2.90) for mild hyponatremia, 3.93 (2.95-5.24) for moderate hyponatremia, 6.98 (2.87-16.40) for severe hyponatremia, 3.65 (2.47-5.40) for mild hypernatremia, 8.58 (4.92-14.94) for moderate hypernatremia, and 55.75 (11.37-273.30) for severe hypernatremia. Hypernatremia was associated with a greater risk of death than hyponatremia. Patients with hyponatremia and hypernatremia had increased LOS times compared to those with normal Na levels. Hyponatremia and hypernatremia were associated with greater rates of hospital admission, ICU admission, mortality, and prolonged hospital LOS times.

'I thought they would do it on the spot': why do people with non-traumatic musculoskeletal pain present to emergency departments?

Objective To investigate the reasons patients with non-traumatic musculoskeletal pain (NTMSP) present to an emergency department (ED), their experience of care and perceptions about managing their condition in the future. Methods A qualitative study using semi-structured interviews with patients with NTMSP presenting to a suburban ED. A purposive sampling strategy included participants with different pain characteristics, demographics and psychological factors. Results Eleven patients with NTMSP who presented to an ED were interviewed, reaching saturation of major themes. Seven reasons for ED presentation were identified: (1) desire for pain relief, (2) inability to access other healthcare, (3) expecting comprehensive care at the ED, (4) fear of serious pathology/outcome, (5) influence of a third party, (6) desire/expecting radiological imaging for diagnosis and (7) desire for 'ED specific' interventions. Participants were influenced by a unique combination of these reasons. Some expectations were underpinned by misconceptions about health services and care. While most participants were satisfied with their ED care, they would prefer to self-manage and seek care elsewhere in the future. Conclusions The reasons for ED presentation in patients with NTMSP are varied and often influenced by misconceptions about ED care. Most participants reported that, in future, they were satisfied to access care elsewhere. Clinicians should assess patient expectations so misconceptions about ED care can be addressed.

Changes in Opioid Prescription Rates at Discharge After Targeted Provider Education in the Emergency Department

Introduction: Opioid-related mortality continues to increase in the United States and emergency departments (ED) are a source of opioid prescribing. A review was conducted of prescribing practices and all prescribers were given targeted education to modify prescribing patterns and facilitate guideline recommended opioid prescribing. This study seeks to evaluate prescribing practices after implementation of the education that occurred December 23 to 31, 2019 on prescribing habits. The pre-education group was defined as the period of January 1, 2019 to December 31, 2019. The post-education group was defined as the period of January 1, 2020 to December 31, 2020. Objective: Evaluate the total number of prescriptions and prescription doses in morphine milligram equivalent (MME) prescribed between pre-education and post-education groups. Secondary endpoints will be an evaluation of the number of doses, length of therapy, and the rates of prescribing per 100 discharges. Methods: A retrospective chart review at a single center suburban ED was conducted comparing prescribing after education was provided. Patients were excluded if they were under the age of 18 years, admitted or transferred to an acute care facility, or prescribed an opioid for a non-analgesic purpose. Results: There was a 34% reduction in the total number of opioid prescriptions from the pre-education group compared to the post-education group (4,253 to 2,818). Between the 2 groups, there was a reduction in MME of 8.8 (92.2 ± 60.4 vs 83.4 ± 60), P < 0.001, number of tablets by 0.9 tablets (13.6 ± 5.2 vs 12.7 ± 5.4), P < 0.001, and day supply by 0.12 (4.45 ± 2.1 vs 4.33 ± 2.0), P = 0.017. Percentage of the total number of opioid prescriptions per 100 discharges decreased by 0.4% from 5.1% to 4.7%. Conclusion: After targeting providers through education, a reduction in opioid prescribing was identified through all endpoints.

Utilizing Point of Care Ultrasound to Evaluate for Small Bowel Obstruction in Emergency Department Patients

Small bowel obstruction (SBO) is a common diagnosis made in the Emergency Department (ED) representing about 15% of hospital admissions for acute abdominal complaints. We sought to investigate if bedside ultrasound as performed by ED physicians is a reliable test to diagnose and rule out SBO. This was a prospective cohort study of nonconsecutive patients who presented to an academic, suburban ED with a census of approximately 100,000 patients per year between November 2018 and May 2019. Patients with a history of prior abdominal surgeries who presented to the ED with nausea and/or vomiting and had a CT Abdomen and Pelvis with PO contrast ordered by their provider were consented for a bedside ultrasound. Interpretation was performed by the physician performing the study at bedside. The physician performing the study identified the largest loops of bowel in each of the four quadrants and measured the identified loops from bowel wall to bowel wall. A diameter of greater than 2.5 cm was considered positive for dilated bowel and probable obstruction. At the completion of the study the physician entered their interpretation of the result which was later reviewed by an ultrasound fellowship-trained physician. There were 101 patients included in the study. Study personnel were accurate in 92% of cases. Overall the sensitivity of point of care ultrasound (POCUS) for SBO was 90% (72.7 to 97.8) and specificity was 92% (82.7 to 96.9). The positive and negative likelihood ratios were 10.76 (4.95 to 23.38) and 0.11 (0.04 to 0.33). Given that our study demonstrated a low negative likelihood ratio, those with low probability of an SBO on history could have an ultrasound examination performed at the bedside which could be sufficient to rule out this disease without requiring patients to undergo further imaging.

Evaluating the Impact of Protocol-Driven Treatment for COVID-19 in an Emergency Department Observation Unit.

Background Hospital overcrowding and operating above capacity have occurred frequently throughout the COVID-19 pandemic. Both phenomena can lead to worsened patient outcomes; thus, it is imperative to find solutions that tackle both. Our goal was to create a treatment protocolfor a subset of patients with mild to moderate COVID-19 infection that would combat inpatient overcrowding by diverting these patients to an emergency department (ED) observation unit (EDOU). This protocol was based on dynamic treatment guidelines and required regular updates to allow our team to provide the most up-to-date care throughout the pandemic. Methods This study is a retrospective chart review of all adult patients seen at twolarge suburban EDs for symptoms related to COVID-19 from April 2020 to January 2022. We subsequently identified adult patients who met the criteria for treatment with our COVID-19 protocol and were placed in our observation unit. These patients were identified using a flag for the protocol orderset within our electronic medical record. Primary outcomes include the need for hospital admission, bounce back rate, and death rate. Results A total of 2,417 patients were treated in our ED observation units using our COVID-19 protocol. Our study population was evenly divided by gender, while a majority self-identified as white (76%). Five hundred two patients (20.8%) required admission to the hospital, and of these, 55 (11%) patients required intensive care unit (ICU) level of care. A total of 27 (1.1%) patientsdied. No deaths occurred for patients that remainedwithin our ED observation units. Bounce back rates at the 48-hour, 72-hour, and seven-day marks were 3.6%, 4.6%, and 7.9%, respectively. Finally, we calculated a total of 284 inpatient days saved with the implementation of our protocol. Conclusion This study shows that our newly created protocol is effective in that it reduces the need for inpatient hospital admissions and results in low bounce back rates. Protocol-driven care in ED observation units can be a powerful tool against hospital overcrowding. Creating such protocols offers opportunities for hospital systems to provide efficient care at a significant cost savings without sacrificing quality of care. Our COVID-19 treatment protocol can be replicated by other hospital systems within their own ED observation units should any future similar outbreaks occur.

A Randomized, Clinical Trial Comparing the Efficacy of a Fascia Release Technique for the Treatment of Acute Ankle Sprains

Acute ankle sprains are treated with ice, elevation, immobilization, and non-steroidal anti-inflammatory drugs. Resolution typically takes days. Osteopathic physicians utilize manipulation for a variety of joint disorders and injuries. Few have been studied in randomized controlled trials and many allopathic physicians are unaware of their utility. One manipulation, a modified muscle energy release technique, appears to offer promise for the treatment of acute ankle injuries, potentially returning patients to function more quickly than standard treatment alone. This study involved a comparison of a modified muscle energy release technique with standard treatment to standard treatment alone in the emergency department (ED) setting for patients with acute ankle injuries. This is an IRB approved, randomized single-blind sham-controlled study on a convenience sample of ED patients with pain from acute inversion injury. The study was set in a suburban ED with a 3-year Emergency Medicine Residency and an annual volume of 80,000. Inclusion criteria were patients aged 18-55 years; a Grade I or II acute ankle sprain less than 48 hours old; initial VAS scores ≥ 35; and being able to take 4 steps in the ED. We excluded fractures and Grade III injuries. The experimental manipulation technique involved placing the ankle into position of injury (inversion) for over 90 seconds and then bringing the ankle back to a neutral position over 90 seconds against mild hand resistance. The sham manipulation was similar but with plantar-flexion manipulation instead Patients were evaluated pre and 5 minutes after manipulation and 2 days later with a 100mm VAS pain scale completed by the patient after taking 4 steps. 17 patients were enrolled, 7 in the experimental (E) and 10 in the sham (S) group; 7 (41%) were female. There was no difference between groups for age (E=32; S=32 years p=0.9), gender (p=0.9), time from injury (E=7 vs S=11 hours; p=0.4) or initial VAS (E= 51 mm (SD 27); S= 57 mm (SD 20) (p=0.7). Both groups had similar distributions of pain (see schematic). There was no difference in mean pain relief between groups immediately after manipulation E=2.4mm (-11.0-15.88, 95%CI) vs S= 7.2mm (0.08-14.8, 95%CI) (p=0.4) or 2 days later E=29.1mm 1mm (8.5-49.7, 95%CI) S=26 (7.7 95%CI (p=0.8). Muscle energy release for acute ankle sprain does not improve pain immediately or in 2 days compared to standard treatment.

Keeping up with the literature: A current practice survey and qualitative needs assessment among emergency physicians.

Physicians face the challenge of staying current with a rapidly growing body of evidence and applying it to their practice. How emergency physicians (EPs) do so is unknown. The authors sought to describe and assess needs around EP patterns of evidence-based medicine (EBM) and continuing medical education (CME) resource use. The authors conducted a multicenter, cross-sectional study in 2019 across 12 tertiary care, community, and suburban emergency department (ED) sites in the greater area of Edmonton. Information on EBM/CME resource use along with barriers and facilitators to staying current was gathered using a rigorously developed survey tool, distributed electronically and by mail. Responses were tabulated and subgroups analyzed using MANOVA and ANOVA tests. Thematic analysis of comments used a phenomenological lens. A total of 118 EPs (40.1%) completed the survey. Listening to podcasts, attending EM conferences, and subscription-based resources were preferred for staying current. Resource use differed by years in practice but not by age, sex, training background, or site type. EBM had an important impact on respondents' practice (average rating 3.8 out of 5, with 5 indicating "practice changing"). Time was an important barrier. Most (62.7%) felt that they did not spend enough time, despite spending a median of 4 to 5h monthly on EBM. Facilitators (including journal club summaries or lists of practice-relevant papers) had only moderate impacts. Thematic analysis found three themes (importance of EBM, implementation challenges, and dissemination of EBM) and 13subthemes. EPs preferentially chose podcasts, conferences, and subscription-based resources to stay current with EBM; time was the biggest barrier. These findings help ED leads and educators tailor CME to physician learning preferences to maximize application of EBM to clinical practice. The next steps include developing/curating resources and disseminating the survey on a larger scale to identify opportunities for shared virtual resources.

Trichomonas Infection Rates in Males Presenting to the Emergency Department for Sexually Transmitted Infections.

Trichomonas vaginalis (TV) is one of the most common sexually transmitted infections (STIs). Overall prevalence is reported to be 3.1%, with rates approaching 12.9-14.4% in high-risk female populations. Although there is a plethora of data on TV in the female population, the corresponding data for the male population are limited. Our aim was to determine the infection rate of TV in male patients seeking care for STIs in the emergency department (ED) and determine the symptoms associated with TV infection in male patients. We conducted a retrospective study of male patients aged 13 years or older who presented to the ED for STI evaluation. Male patients included had nucleic acid amplification test (NAAT) TV testing as part of standard STI evaluation. Of the 2137 male patients included, 95 (4.4%) were positive for TV. Male patients who tested positive were significantly older (mean age 38.9 years vs. 30.7 years for male patients who tested negative; p < 0.05). Black male patients were more likely than White male patients to be positive for TV (6.3% prevalence vs. 1.8%; p < 0.05). TV-positive male patients were more likely to have discharge, specifically clear penile discharge, on examination (p < 0.05), and were less likely to have testicular pain or testicular tenderness (p < 0.05). Higher rates of TV were seen in an urban (4.9%) compared with suburban ED (1.6%; p < 0.05). Rates of TV in male patients who receive STI testing in the ED are similar to rates published previously for female patients. We found higher rates among older and African-American male patients. TV among male patients is prevalent and testing should continue when evaluating for STIs.

Examination of physician characteristics in opioid prescribing in the emergency department.

We aimed to better understand variation in opioid prescribing practices by investigating physician factors at one academic suburban Emergency Department (ED). We retrospectively reviewed the electronic medical records of all patients given opioid prescriptions in the Stanford Health Care ED from 2009 to 2018. We described the variation in opioid prescriptions over time from 2009 to 2018, then dove deeper into a single year (July 1, 2017 to July 1, 2018). We described the number and type of opioid prescriptions at discharge and variation in attending physician opioid prescribing patterns using independent t-tests and a Fischer's exact test. From 2009 to 2018, 657,037 patient visits occurred; 92,612 (14.1%) opioid prescriptions were written. Opioid prescriptions increased from 2009, peaked in 2015, then decreased. Individual providers wrote opioid prescriptions for 1 to 17% of their discharged patients. There was no significant difference in opioid prescribing based on provider gender (p = 0.456), fellow or attending status (p = 0.390), residency completed at Stanford Hospital (p = 0.593), residency completed within California (p = 0.493), or residency completed after 2010 (p = 0.589). Of the 371 providers who wrote opioid prescriptions from 2009 through 2018, 120 wrote prescriptions for patients who had already received at least three opioid prescriptions in the same year from the same department. This study could inform policymakers by describing patterns of variation in opioid prescribing over time and between providers. Although we did see significant differences in prescribing patterns from one provider to the next, those were not explained by the factors we examined. Further studies could investigate factors such as provider experience with pain and addiction, bias regarding particular pathologies, and concern around patient satisfaction scores.

Clinical Nurse Specialist Practice: Impact on Emergency Department Blood Culture Contamination.

Blood culture collection is a common procedure performed in emergency departments. Rate of blood culture contamination is a metric that is tracked by organizations to ensure appropriate treatment for patients suspected of having bacteremia and ensure appropriate use of hospital resources. A team of nurses and technicians undertook a quality improvement project to decrease blood culture contamination rates in a suburban emergency department. The project included use of standardized blood culture collection kits, creation of a dedicated collection team, and implementation of a new blood culture collection device. Through this work, blood culture contamination rates decreased from greater than 3.0% to less than 1.5% consistently for nearly 24 months. Providing feedback and continued monitoring has made this quality improvement initiative a success for the department and the organization and has resulted in cost savings of nearly 2 million dollars.

68 Back Pain Patient Satisfaction Scores Did Not Change after Legislation Resulting in Opiate Prescription Decrease

In response to the opiate crisis, New Jersey (NJ) enacted legislation in February 2017 that required physicians, when prescribing opiates, to look up patients’ previous opiate prescription history, counsel safe opiate use and document all this in the emergency department (ED) chart. We previously found ED opiate prescriptions markedly decreased by 62% in the ten months after the legislation. We hypothesized that the decrease in ED opiate prescriptions would lead to a drop in ED back pain patient satisfaction scores. Retrospective multihospital cohort of ED visits. The setting was 16 NJ urban and suburban EDs with annual visits from 21,000 to 99,000. Consecutive patients seen by ED physicians from 1/1/2016 to 8/31/2018. Using ICD 10 codes, we identified back pain patients. For patient satisfaction, we used the results of a mailed survey (Press Ganey Associates). Although the return rate on this survey is low, the survey is widely used nationally to judge performance in the ED. We computed and plotted the average ED physician patient satisfaction scores for each month over the time period of the study. A priori we chose to calculate the average satisfaction score for the 12 months before and the 12 months after February 2017 (See Table). We also calculated the linear regression coefficient of the plot for the entire period (1/1/2016 to 8/31/2018). Of the 3,888,502 visits in the database, 112,296 were for back pain and of these 1523 surveys were returned. There was no change in the average ED physician patient satisfaction scores for the 12 months before and after February 2017 (average score = 84 for both periods). The linear regression coefficient of the plot for the entire period 1/1/2016 to 8/31/2018 was R squared = 0.0004 (p = 0.91). Contrary to our hypothesis, there was no change in ED back pain patient satisfaction scores after legislation, despite a marked decrease in ED opiate prescriptions.Tabled 112 months before and 12 months after February 2017Back painYear and month of serviceVisitsAvg Satisfaction ScoreAvg Doc Score# of Responses2016023,33085.385.66012016033,44482.984.83812016043,48982.380.05312016053,50381.982.74412016063,47585.182.74612016073,57688.388.36612016083,53382.782.04412016093,53286.987.74212016103,62184.383.86612016113,18087.685.44112016123,46584.183.25712017013,60481.481.4411averages84.484.049.8122017033,42086.386.75812017043,61079.878.44512017053,86279.478.05612017063,72184.685.54612017073,70985.284.24012017083,82091.192.14012017093,47687.386.65012017103,73088.588.35412017113,47185.586.64312017123,25682.880.74712018013,66385.083.63812018023,18481.478.1441averages84.884.146.812 Open table in a new tab

Diagnostic yield of computed tomographic pulmonary angiography for suspected pulmonary embolism varies across settings within a community-based health system.

The diagnostic yield of computed tomographic pulmonary angiography (CTPA) for pulmonary embolism varies in the literature, and very little data is available regarding community-based systems. This study evaluates the yield of CTPA for pulmonary embolism across a variety of patient care settings in a community-based healthcare system, providing relevant benchmarks for potential quality improvement efforts. This retrospective study included data collected from three sites within a single community-based healthcare system, including a tertiary care level 1 trauma center, an urban community hospital, and a suburban free-standing emergency department. CTPAs were identified by Current Procedural Terminology codes, and diagnoses of pulmonary embolism were identified via International Classification of Diseases codes. A total of 7850 CTPA studies met criteria for inclusion between January 1, 2012, and October 8, 2014. Pulmonary embolism was found in 884 (11.3%) of the studies performed. Outpatients had a lower yield of pulmonary embolism (3.8%, p < 0.001) compared with inpatients (14.1%) and emergency department patients (10.7%, p < 0.001). Patients with diagnoses of deep vein thrombosis or neoplasm had increased incidence of pulmonary embolism when compared with patients without these diagnoses (p < 0.001 for both). The overall yield of CTPA for pulmonary embolism in this community-based system was similar to that at academic centers. The yield was significantly lower in the outpatient setting compared with studies originating in the emergency department or inpatient setting.

Positive Tests for Lyme Disease and Emergency Department Visits for Bell's Palsy Patients.

Etiologies for Bell's palsy include herpes viruses and Lyme disease, with highest incidence in the colder and warmer months, respectively. In New Jersey, a Lyme-endemic area, the months with the most Lyme disease (80% of cases) are May through October ("Lyme months"). Our aim was to determine whether positive tests for Lyme disease and visits are greater in the Lyme months than the rest of the year for patients with Bell's palsy in New Jersey emergency departments (EDs). We conducted a retrospective chart review from two New Jersey suburban EDs with consecutive patients from February 1, 2013 to January 31, 2018.We identified patients having Bell's palsy using the emergency physician diagnosis. We tabulated positive Lyme tests and visits for Bell's palsy by month of year. We calculated the ratio of positive tests and visits between the Lyme months and the rest of the year along with 95% confidence intervals (CIs). There were 442 visits for Bell's palsy, 359 (81%) of these patients were tested for Lyme disease and 57 (16%) of the tests were positive. The Lyme months had 7.1 (95% CI 3.5-14.4) times more positive tests and 1.3 (95% CI 1.1-1.4) times more Bell's palsy visits than the rest of the year. Both measures peaked in July. In a Lyme-endemic area, positive Lyme tests and ED visits for Bell's palsy are greatest in the Lyme months, peaking in July. This finding can help guide testing and treatment for patients in the ED with Bell's palsy during various months of the year.

Association of Pain Location With Computed Tomography Abnormalities in Emergeny Department Patients With Abdominal Pain.

Over the last decade the usage of computed tomography (CT) imaging has risen dramatically in emergency department (ED) patients with abdominal pain. Recognizing the potential disadvantages of overuse of CT imaging, efforts are being made to reduce imaging. We determined the operating characteristics for location of abdominal pain for the entities of acute appendicitis, diverticulitis, and intestinal obstruction. We hypothesized that patients with pain localized to the upper abdomen would be less likely to have CT abnormalities than those with lower abdominal pain. This is a prospective, observational registry of ED patients with abdominal pain, performed in an academic, suburban ED with an annual census of 110,000. Presence of clinically significant CT abnormalities (e.g., appendicitis, diverticulitis, bowel obstruction) were recorded along with clinical variables including laboratory values, vital signs, reported location of pain, location of tenderness on examination, and physician pretest probability. A convenience sample of 1154 patients was enrolled. Of all patients, 273 cases (24%) had abnormal CT results, including appendicitis (n=95), diverticulitis (n=133), and bowel obstruction (n=49). Right upper quadrant pain was negatively associated with abnormal CT (p=0.02). Clinician gestalt was highly specific, but lacked sensitivity for the diagnosis of appendicitis, diverticulitis, and obstruction. Twenty-four percent of patients diagnosed with appendicitis had no right lower quadrant pain or tenderness, and 7% of patients with diverticulitis had no left lower quadrant pain or tenderness. Localization of abdominal pain by history or physical examination is not sufficient to accurately diagnose intra-abdominal pathology, especially cases of acute appendicitis, diverticulitis, or intestinal obstruction.

Optimizing the workforce: a proposal to improve regionalization of care and emergency preparedness by broader integration of pediatric emergency physicians certified by the American Board of Pediatrics.

BackgroundEmergency care in the United States faces notable challenges with regard to children. In some jurisdictions, available resources are not sufficient to meet local needs. Physicians with specialty training in pediatric emergency care are largely concentrated in children's medical centers within larger urban areas. Rural emergency facilities, which are more likely to face ongoing staffing shortages in all specialties, are particularly deficient in pediatric emergency medicine (PEM) physicians. This paper addresses challenges in distribution of pediatric emergency care specialists into suburban and rural health care facilities, and proposes potential local and regional solutions to improve pediatric emergency care capabilities as well as to enhance disaster response in children.ObjectivesThe American College of Emergency Physicians (ACEP) committee on PEM generated the objective to study and explore methods and strategies to address current challenges and shortcomings in the distribution of pediatric emergency physicians and to develop recommendations to improve access to emergency pediatric expertise in all care settings. A sub‐committee was formed to generate a written report followed by full committee input. The content was reviewed by the ACEP Board of Directors.DiscussionPediatric emergency physicians are certified either by the American Board of Emergency Medicine or the American Board of Pediatrics (ABP) depending on whether their training occurred through the emergency medicine or a pediatric residency program. ABP‐certified PEM that account for the majority of PEM physicians, remain largely concentrated in urban tertiary pediatric care centers, primarily children's hospitals. By contrast to the resources, the majority of pediatric patients receive emergency care in emergency departments (EDs) outside this setting. The goal of our recommendations is to help regionalize PEM expertise, allowing sharing of such resources with facilities that have traditionally not had access to PEM expertise. Financial or low number of pediatric cases likely contributed to lack of PEM resources in suburban and rural EDs, although a significant factor for lack of access to ABP‐certified PEM physicians may be local privilege and practice restrictions. Expanding the scope of practice for ABP‐certified PEM physicians beyond traditionally assigned arbitrary age limits to include selective adult patients has the potential to alleviate credentialing barriers and offset the financial and volume concerns while enhancing preparedness efforts, resource utilization, and access to specialized pediatric emergency care.ConclusionRecognition that the training of ABP‐certified PEM physicians allows for these individuals to safely care for selective adult patients with common disease patterns that extend beyond traditionally assigned arbitrary pediatric age limits has the potential to improve resource dissemination and utilization, allowing for greater access to pediatric emergency physicians in currently underserved settings.